AF and in-hospital mortality in COVID-19 patients.

Background: There are conflicting data on whether new-onset atrial fibrillation (AF) is independently associated with poor outcomes in COVID-19 patients. This study represents the largest dataset curated by manual chart review comparing clinical outcomes between patients with sinus rhythm, pre-existing AF, and new-onset AF. Objective: The primary aim of this study was to assess patient outcomes in COVID-19 patients with sinus rhythm, pre-existing AF, and new-onset AF. The secondary aim was to evaluate predictors of new-onset AF in patients with COVID-19 infection. Methods: This was a single-center retrospective study of patients with a confirmed diagnosis of COVID-19 admitted between March and September 2020. Patient demographic data, medical history, and clinical outcome data were manually collected. Adjusted comparisons were performed following propensity score matching between those with pre-existing or new-onset AF and those without AF. Results: The study population comprised of 1241 patients. A total of 94 (7.6%) patients had pre-existing AF and 42 (3.4%) patients developed new-onset AF. New-onset AF was associated with increased in-hospital mortality before (odds ratio [OR] 3.58, 95% confidence interval [CI] 1.78-7.06, P < .005) and after (OR 2.80, 95% CI 1.01-7.77, P < .005) propensity score matching compared with the no-AF group. However, pre-existing AF was not independently associated with in-hospital mortality compared with patients with no AF (postmatching OR: 1.13, 95% CI 0.57-2.21, P = .732). Conclusion: New-onset AF, but not pre-existing AF, was independently associated with elevated mortality in patients hospitalised with COVID-19. This observation highlights the need for careful monitoring of COVID-19 patients with new-onset AF. Further research is needed to explain the mechanistic relationship between new-onset AF and clinical outcomes in COVID-19 patients.

The Impact of Atrial Fibrillation Treatment Strategies on Cognitive Function.

There is increasing evidence to suggest that atrial fibrillation is associated with a heightened risk of dementia. The mechanism of interaction is unclear. Atrial fibrillation-induced cerebral infarcts, hypoperfusion, systemic inflammation, and anticoagulant therapy-induced cerebral microbleeds, have been proposed to explain the link between these conditions. An understanding of the pathogenesis of atrial fibrillation-associated cognitive decline may enable the development of treatment strategies targeted towards the prevention of dementia in atrial fibrillation patients. The aim of this review is to explore the impact that existing atrial fibrillation treatment strategies may have on cognition and the putative mechanisms linking the two conditions. This review examines how components of the 'Atrial Fibrillation Better Care pathway' (stroke risk reduction, rhythm control, rate control, and risk factor management) may influence the trajectory of atrial fibrillation-associated cognitive decline. The requirements for further prospective studies to understand the mechanistic link between atrial fibrillation and dementia and to develop treatment strategies targeted towards the prevention of atrial fibrillation-associated cognitive decline, are highlighted.

Transient unilateral weakness: is it a transient ischaemic attack?

Transient ischaemic attack is an emergency medical condition that causes brief negative focal neurological symptoms such as unilateral weakness. The symptoms herald a high risk of stroke and hence require urgent assessment. The challenge lies in the brevity and compendium of associated symptoms that can 'mimic' a plethora of other conditions. The result is a high rate of referrals to transient ischaemic attack clinics for these stroke mimics. This article highlights the diagnostic challenges in transient ischaemic attack with relevance to unilateral weakness.

Improving stroke pathways using an adhesive ambulatory ECG patch: reducing time for patients to ECGs and subsequent results.

Three south-London hospital trusts undertook a feasibility study, comparing data from 93 patients who received the 14-day adhesive ambulatory electrocardiography (ECG) patch Zio XT with retrospective data from 125 patients referred for 24-hour Holter for cryptogenic stroke and transient ischaemic attack following negative 12-lead ECG. As the ECG patch was fitted the same day as the clinical decision for ambulatory ECG monitoring was made, median time to the patient having the monitor fitted was significantly reduced in all three hospital trusts compared with 24-hour Holter being ordered and fitted. Hospital visits reduced by a median of two for patients receiving Zio XT. This project supports that it is feasible to use a patch as part of routine clinical care with a positive impact on care pathways.

Prognosis in dysphagic patients who are eating and drinking with acknowledged risk: results from the evaluation of the FORWARD project.

BACKGROUND: patients with a permanently unsafe swallow may choose to eat and drink with acknowledged risk (EDAR). Informed decision-making and advance care planning depend on prognosis, but no data have yet been published on outcomes after EDAR decisions. METHODS: the study was undertaken in 555 hospital inpatients' (mean [SD] age: 83 {12}) EDAR supported by the Feeding via the Oral Route with Acknowledged Risk of Deterioration care bundle between January 2015 and November 2019. Data were collected prospectively on clinical characteristics, dates of discharge, readmissions and death (where relevant). Kaplan-Meier survival functions and readmission risks per surviving patient per month were calculated. RESULTS: mortality is 56% in the first 3 months after discharge but then mortality risk sharply decreases. The 3-month survival in EDAR patients was more likely in those <75 years of age, those with Parkinson's disease or a structural oral lesion as the dominating cause of dysphagia and those with mental capacity regarding EDAR decisions. Readmission risk in the 3 months post-discharge is 21% but reduces to 12% thereafter (P < 0.001). Thirty-eight percent of readmissions are secondary to EDAR-linked conditions such as chest infections and reduced oral intake. CONCLUSION: there is a high mortality and readmission risk after an EDAR decision but much of this is frontloaded into the first 3 months, with a relatively favourable prognosis thereafter. This may be an appropriate time-point to reassess the plan for eating and drinking such that it continues to reflect the most appropriate balance of risk, comfort and nutrition.

Multifactorial Interventions to Reduce Duration and Variability in Delays to Identification of Serious Injury After Falls in Hospital Inpatients.

OBJECTIVES: Inpatient falls are the most commonly reported safety incidents and are associated with serious injuries. This study aimed to use multifactorial interventions to reduce the delays to the diagnosis of serious injury in a time series analysis after serious incidents relating to falls within a central London Trust. METHODS: A multiprofessional project team undertook process mapping to identify opportunities for improvement at different stages in the management of a fall. The interventions included an educational teaching session aimed at doctors, a lanyard card designed by doctors using the plan-do-study-act methodology, a falls-specific pager for radiographers, and a new system to refer to portering. Quantitative data were obtained using an serious incident database where serious injury occurred (SI data; n = 65) and routinely collected incident reporting database on falls regardless of injury (IR data; n = 178). Qualitative questionnaire data (n = 70) were also used to evaluate doctors' confidence in falls assessment before and after interventions. RESULTS: Results in the IR data demonstrated a significant reduction in the median (interquartile range) minutes delay in the time to review a patient after a fall from 81 (43-180) to 51 (26-112; P = 0.003) and the time to order imaging from 102 (45-370) to 50 (33-96; P = 0.04). Analysis of the SI database demonstrated a nonstatistically significant reduction in the overall time taken to detect serious injury after a fall from 348 (126-756) to 192 (108-384) minutes (P = 0.070). Furthermore, analysis using statistical process control charts showed evidence of special cause variation and a shift in the process in detecting serious harm after a fall. Junior doctors' confidence in investigations improved from 53% to 76% (P = 0.04) after the intervention. CONCLUSIONS: The cumulative application of multiple interventions with small individual effects resulted in a substantial positive effect on delays and variability in diagnosis of serious harm. Given a similar institutional context, the more effective interventions in our study could be adopted elsewhere.

Approaches to Eating and Drinking with Acknowledged Risk: A Systematic Review.

BACKGROUND: Patients with dysphagia may consider eating and drinking with acknowledged risk (EDAR) instead of artificial hydration/nutrition. Timely consideration of complex issues is required including dysphagia reversibility, risk/benefit discussions, patient wishes, their capacity and best interests. OBJECTIVE: This study aimed to establish if EDAR protocols improve care through a systematic literature review with a secondary aim to explore important factors for the development and success of a protocol. METHODS: PUBMED, MEDLINE, CINAHL and EMBASE were searched for English language articles to May 2019 with terms related to EDAR, dysphagia and end of life. Articles were agreed for inclusion by three independent reviewers. Levels of evidence were assessed using the modified Sackett scale. Study themes were identified and discussed. RESULTS: 8 articles met the inclusion criteria with varied methodology. The highest level of evidence was III (cohort study). Most were limited to patients with dementia, stroke, in older person's wards or residential homes. Three articles described a systematic approach to EDAR for in-patients, reporting reductions in days nil-by-mouth until feeding plans are made and improvements in documentation of decision making, nutrition plans and capacity assessment. Five papers explored the views and knowledge of staff, patients and families/carers relating to EDAR and complex feeding decisions. Formal meta-analysis was not possible due to the level and mix of methodology. CONCLUSION: There is a paucity of evidence to determine if EDAR protocols improve care. However, support is emerging for a coordinated approach to managing EDAR. Findings suggest having a protocol is not enough; training and communication within teams is essential, together with incorporating feedback from patients and carers, and this justifies further work.

FORWARD (Feeding via the Oral Route With Acknowledged Risk of Deterioration): evaluation of a novel tool to support patients eating and drinking at risk of aspiration.

BACKGROUND: care of patients with a permanently unsafe swallow who are inappropriate for tube feeding is challenging. Eating and drinking with acknowledged risk (EDAR) may be an appropriate strategy but without clear decision making and communication patients may spend unnecessarily long 'nil by mouth' (NBM), they or their family may experience significant anxieties and advance care plans may not be made. METHODS: the FORWARD (Feeding via the Oral Route With Acknowledged Risk of Deterioration) care bundle was sequentially co-designed and embedded across different in-patient clinical services using 'plan-do-study-act' methodology to systematise best practice. Care before and after FORWARD's implementation was evaluated using a time-series analysis of 305 'EDAR patients' (19 in 6 months pre-FORWARD; 42 in a 12-month 'pilot'; 244 patients in the subsequent 27 months). RESULTS: median (IQR) days patients were NBM without an alternative feeding route reduced significantly from 2 (1-4) pre-FORWARD to 0 (0-2) in the 'pilot' and 0 (0) post-'pilot' (P < 0.05). G-chart analysis demonstrated sustained performance across time and different clinical settings. Implementation of FORWARD significantly improved documentation of capacity assessment (42%→98%), discussions with next of kin (47%→98%) and onward communication of feeding plans (67%→81%). In wards where FORWARD was introduced, rate of aspiration pneumonia (a 'balancing measure' sensitive to harm associated with EDAR) increased at half the rate of dysphagia (0.8%/year versus 1.6%/year). CONCLUSION: the FORWARD care bundle supported complex decision-making around EDAR in patients with persistent dysphagia. The benefits of FORWARD were shown to be sustained over time and in a wide in-patient context.

Improving the care of patients feeding at risk using a novel care bundle.

Feeding with acknowledged risk is appropriate for patients unsuitable for tube feeding who have an unsafe swallow that is unlikely to improve. However, without excellent multidisciplinary decision making and communication, patients may spend unnecessarily long 'nil by mouth' (NBM) and advance feeding/care plans may not be made or communicated. The FORWARD bundle (Feeding via the Oral Route With Acknowledged Risk of Deterioration) was sequentially co-designed and embedded across different services using 'plan-do-study-act' methodology to systematise best practice. Care before and after FORWARD was evaluated using a time-series analysis of 80 patients who had been risk-fed. Time NBM without tube feeding improved from 2 to 0 days (p=0.02) with significantly better documentation of capacity assessments and discussions with next of kin. There were sustained trends to improved rates of best interest discussions and communication of feeding plans to downstream care providers. The significance and applicability of these findings is discussed.